INTUBATION

REVIEW

SFC HILL

Joint Special Operations Medical Training Center

 Advantages/Complications
of Tracheal Intubation

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 Advantages of tracheal
intubations:
• Airway patency
– Protects the airway
– Maintains patency during positioning
• Control of ventilation
– ventilation over a long period of time
without intubation can lead to gastric
distention and regurgitation

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 Advantages of tracheal
intubations:
• Route for inhalation anesthesia and
emergency medications
• N - Narcan
• A - Atropine
• L - Lidocaine
• E - Epinephrine

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 Complications of tracheal
intubation:
• Trauma to the lips, teeth, and soft
tissues of the airway.
– Awareness
– meticulous technique
• Bronchial intubation
– frequent complication
– auscultation of the chest bilaterally

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 Complications of tracheal
intubations:
• Laryngospasm
– common when extubation is done when
the patient is in a semiconscious state
– extubation should be done in a
relatively deep anesthesia or when the
protective laryngeal reflex has returned
• Postintubation hoarseness and sore
throat
– due to mechanical presence of the
tracheal tube
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 Preparation of Equipment
• Assemble pharyngeal airways in
assorted sizes
– Nasopharyngeal
– Oropharyngeal
• Inspect laryngoscope for serviceability
– Batteries
– Light bulb
– Blades; curved/straight (Macintosh or
Miller)
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 Selection of laryngoscope
blade (preference)
• Macintosh is a curved blade whose tip
is inserted into the vallecula (the space
between the base of the tongue and the
pharyngeal surface of the epiglottis).
Most adults require a Macintosh number
3 or 4 blade.

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 Selection of laryngoscope
blade (preference)
• Miller is a straight blade that is passed
so that the tip of the blade lies beneath
the laryngeal surface of the epiglottis.
The epiglottis is then lifted to expose the
vocal cords. Most adults require a Miller
number 3 blade.

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 Preparation of Equipment -
Inspect endotracheal tubes
• Tube size
• adult male 8 mm to 9 mm tube
• adult female 7 mm to 8 mm tube
• Tube length- extend from the lower
incisor to a point midway between
the cricoid cartilage and Louis's
angle (the sternal angle) on the
patient
• Endotracheal tube cuff
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 Preparation of Equipment
• Malleable stylet (should not extend
past Murphy's eye)
• Lubrication
• Laryngeal sprays

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 Inspect resuscitator (AMBU
bag) for serviceability
• Bag
• Mask
• Intake valve
• Valve body with relief valve

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 Inspect stethoscope
• Diaphragm
• Earpieces
• Tubing

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 Gather and prepare all
equipment necessary for an
emergency Airway
• Scalpel handle
• Surgical blades
• Curved hemostats
• Endotracheal tube
• Syringe

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 Intubation Technique
• ventilate with 100 percent oxygen for
approximately 1 min
• Position bed height to bring the patient's
head to a mid-abdominal height
• Flex the cervical spine and extend the
head at the atlanto-occipital joint
• Long axis of the oral cavity, pharynx, and
trachea lie almost in a straight line

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 Intubation Technique
• introduce the blade into the right side of
the patient's mouth
• move the blade posteriorly and toward the
midline, sweeping the tongue to the left
and keeping it away from the visual path
with the flange of the blade
• ensure the lower lip is not being pinched
by the lower incisors and laryngoscope
blade
• advance the laryngoscope until the
epiglottis is in view
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 Intubation Technique
• lift the laryngoscope upward and forward
• insert the endotracheal tube from the right
with its concave curve facing downward
and to the right side of the patient
• maneuver the endotracheal tube into the
larynx, midway between the cricoid
cartilage and the sternal angle

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 Intubation Technique
• inflate the cuff and apply positive
pressure ventilation while the
assistant auscultates
• secure the endotracheal tube in
position

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 Curved Blade Technique
The curved blade technique is
essentially similar. The only
difference being when the epiglottis
is in view, advance the tip of the
laryngoscope blade into the
vallecula, formed by the base of the
tongue and the epiglottis; lift upward
and forward.

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 Nasotracheal intubation
technique
• topical lidocaine or phenylephrine should
be applied to the nasal passages
• 0.5-1.0% Neosynephrine and 4%
Lidocaine, mixed 1:1 should also give
satisfactory results
• generously lubricate the nares and
endotracheal tube
• ET tube should be advanced through the
nose directly backward toward the
nasopharynx
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 Nasotracheal intubation
technique
• loss of resistance marks the
entrance into the oropharynx
• laryngoscope and Magill forceps can
be used to guide the endotracheal
tube into the trachea under direct
vision
• for awake spontaneous breathing
patients, the blind technique can be
used
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 Confirmation of tracheal
intubation:
• Direct visualization of the ET tube
passing through the vocal cords
• CO2 in exhaled gases
• Bilateral breath sounds
• Absence of air movement during
epigastric auscultation

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 Confirmation of tracheal
intubation:
• Condensation (fogging) of water vapor in
the tube on exhalation
• Refilling of reservoir bag during
exhalation
• Maintenance of arterial oxygenation
• Chest X-ray: the tip of the ET tube should
be between the carina and thoracic arc or
approximately at the level of the aortic
arch
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 Extubation
• ensure that the patient is recovering
is breathing spontaneously with
adequate volumes
• evaluate the patient's ability to
protect his airway by observing
whether the patient responds
appropriately to verbal commands

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 Extubation steps:
• Oxygenate patient with 100 percent
high flow O2 for 2 to 3 minutes
• if secretions are suspected in the
tracheobronchial tree, remove them
with a suction catheter through the
lumen of the endotracheal tube
• ensure that the patient is not in a
semiconscious state
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 Extubation steps:
• turn the patient onto his side if he is still
unconscious
• unsecure the endotracheal tube from the
patient's face
• deflate the cuff and remove the
endotracheal tube quickly and smoothly
during inspiration
• continue to give the patient O2 as required

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